**Introduction/Hypothesis:**
A 75-year-old male with known medical history of obstructive sleep apnea (OSA) and hypertension, presented to the outpatient clinic due to excessive fatigue, irregular heart beat and bradycardia. He denied chest pain or pressure, claudication, dyspnea, history of stroke, or syncopal episode. His medications were losartan 50 mg daily and simvastatin 20mg daily. Due to the constellation of symptoms, an ischemic evaluation was initiated with an ECG revealing sinus bradycardia and Holter monitor with occasional premature ventricular contractions. A transthoracic echocardiogram revealed bicuspid aortic valve and an enlarged sinus of Valsalva diameter of 49 mm (upper limit of normal 42 mm per Body Surface Area and age) and enlarged proximal ascending aorta diameter of 48 mm. The left ventricle with a normal ejection fraction of 68% with no regional wall motion abnormality. He had a stress exercise echocardiogram positive for ischemia which led to a coronary CT angiogram. It demonstrated significant coarctation of the aorta, distal to the takeoff of the left subclavian with minimal luminal diameter of 7 mm. He was referred to the Adult Congenital Heart Disease clinic for consultation and management. A CT thoracic and head/neck angiogram to assess arterial beds. Thoracic CTA demonstrated a post-ductal coarctation of the aorta in the proximal descending portion (Figure 1). Based on these findings, patient was referred to our interventional team for consideration of percutaneous therapy.

**Methods**
n/a

**Results**
After his evaluation by the Interventional Adult and Pediatric Cardiology team, plan was to proceed intervention for his severe native coarctation with a 10 zig long covered stent Covered Cheatham Platinum Stent (CCPS). A coronary angiography was performed through the left subclavian artery pigtail catheter into the descending aorta to outline the pre-coarctation segment and additional angiography to confirm the entry of the transverse arch (Figure 2). The narrowest segment measured approximately 7 mm. An 0.035" Amplatz Extra Stiff exchange guidewire was secured in the left subclavian artery. The 18 French Gore Dry Seal sheath was exchanged for the short sheath over this guidewire and advanced into the aorta above the coarctation. The 10 zig, 6.0 cm length CCPS was re-crimped and advanced through the sheath into the region of coarctation and was gradually uncovered. The inner balloon inflation was performed while on fluoroscopy via the left subclavian pigtail confirming excellent positioning. The outer balloon was then fully inflated to deliver the stent. It was then exchanged the balloon-in-balloon (BIB) for a 20 mm noncompliant Atlas balloon which was advanced into the waist of the stent. The stent was in stable position and appeared well expanded with no evidence of residual pressure gradient (Figure 2). He was then discharged on aspirin 81mg for at least 6 months and close follow up with the adult congenital heart disease clinic.

**Conclusion**
Coarctation of the aorta (CoA) occurs in approximately 4 of 10,000 live births and seen in 5 to 8% of congenital heart disease.[1] Interventions have been developed such as the balloon angioplasty of native CoA. However, due to its high risk of aortic wall injury and recurrent obstruction, it has been an off label used. To prevent these injuries which include dissection, aneurysm and rupture, covered stents have been used for transcatheter treatment of native and recurrent CoA as noted on the he COAST II (Coarctation of the Aorta Stent) trial.[2, 3] A large diameter covered stents are an appealing nonsurgical option to effectively treat existing aortic wall injury and may prevent it in those patients who are high risk. Placement of the CCPS has a high rate of technical success and short-term hemodynamic improvement (improvement in peak ascending–descending aorta gradient).[2] It is believed that these short-term results support the use of covered stents as a safe and effective treatment option for coarctation of the aorta. Our patient, although had no childhood history of obvious cardiac disease, he had a history of systemic hypertension for approximately 30 years and undiagnosed bicuspid aortic valve. The use of cardiac imaging helped determined this incidental finding and management with the help of a multidisciplinary team approach.

References:
1. Ing, F.F., et al., Early Diagnosis of Coarctation of the Aorta in Children: A Continuing Dilemma. Pediatrics, 1996. 98(3): p. 378-382.
2. Taggart, N.W., et al., Immediate Outcomes of Covered Stent Placement for Treatment or Prevention of Aortic Wall Injury Associated With Coarctation of the Aorta (COAST II). JACC: Cardiovascular Interventions, 2016. 9(5): p. 484-493.
3. Meadows, J., et al., Intermediate Outcomes in the Prospective, Multicenter Coarctation of the Aorta Stent Trial (COAST).Circulation, 2015. 131(19): p. 1656-1664.



**Introduction/Hypothesis:**
A 75-year-old male with known medical history of obstructive sleep apnea (OSA) and hypertension, presented to the outpatient clinic due to excessive fatigue, irregular heart beat and bradycardia. He denied chest pain or pressure, claudication, dyspnea, history of stroke, or syncopal episode. His medications were losartan 50 mg daily and simvastatin 20mg daily. Due to the constellation of symptoms, an ischemic evaluation was initiated with an ECG revealing sinus bradycardia and Holter monitor with occasional premature ventricular contractions. A transthoracic echocardiogram revealed bicuspid aortic valve and an enlarged sinus of Valsalva diameter of 49 mm (upper limit of normal 42 mm per Body Surface Area and age) and enlarged proximal ascending aorta diameter of 48 mm. The left ventricle with a normal ejection fraction of 68% with no regional wall motion abnormality. He had a stress exercise echocardiogram positive for ischemia which led to a coronary CT angiogram. It demonstrated significant coarctation of the aorta, distal to the takeoff of the left subclavian with minimal luminal diameter of 7 mm. He was referred to the Adult Congenital Heart Disease clinic for consultation and management. A CT thoracic and head/neck angiogram to assess arterial beds. Thoracic CTA demonstrated a post-ductal coarctation of the aorta in the proximal descending portion (Figure 1). Based on these findings, patient was referred to our interventional team for consideration of percutaneous therapy.

**Methods**
n/a

**Results**
After his evaluation by the Interventional Adult and Pediatric Cardiology team, plan was to proceed intervention for his severe native coarctation with a 10 zig long covered stent Covered Cheatham Platinum Stent (CCPS). A coronary angiography was performed through the left subclavian artery pigtail catheter into the descending aorta to outline the pre-coarctation segment and additional angiography to confirm the entry of the transverse arch (Figure 2). The narrowest segment measured approximately 7 mm. An 0.035" Amplatz Extra Stiff exchange guidewire was secured in the left subclavian artery. The 18 French Gore Dry Seal sheath was exchanged for the short sheath over this guidewire and advanced into the aorta above the coarctation. The 10 zig, 6.0 cm length CCPS was re-crimped and advanced through the sheath into the region of coarctation and was gradually uncovered. The inner balloon inflation was performed while on fluoroscopy via the left subclavian pigtail confirming excellent positioning. The outer balloon was then fully inflated to deliver the stent. It was then exchanged the balloon-in-balloon (BIB) for a 20 mm noncompliant Atlas balloon which was advanced into the waist of the stent. The stent was in stable position and appeared well expanded with no evidence of residual pressure gradient (Figure 2). He was then discharged on aspirin 81mg for at least 6 months and close follow up with the adult congenital heart disease clinic.

**Conclusion**
Coarctation of the aorta (CoA) occurs in approximately 4 of 10,000 live births and seen in 5 to 8% of congenital heart disease.[1] Interventions have been developed such as the balloon angioplasty of native CoA. However, due to its high risk of aortic wall injury and recurrent obstruction, it has been an off label used. To prevent these injuries which include dissection, aneurysm and rupture, covered stents have been used for transcatheter treatment of native and recurrent CoA as noted on the he COAST II (Coarctation of the Aorta Stent) trial.[2, 3] A large diameter covered stents are an appealing nonsurgical option to effectively treat existing aortic wall injury and may prevent it in those patients who are high risk. Placement of the CCPS has a high rate of technical success and short-term hemodynamic improvement (improvement in peak ascending–descending aorta gradient).[2] It is believed that these short-term results support the use of covered stents as a safe and effective treatment option for coarctation of the aorta. Our patient, although had no childhood history of obvious cardiac disease, he had a history of systemic hypertension for approximately 30 years and undiagnosed bicuspid aortic valve. The use of cardiac imaging helped determined this incidental finding and management with the help of a multidisciplinary team approach.

References:
1. Ing, F.F., et al., _Early Diagnosis of Coarctation of the Aorta in Children: A Continuing Dilemma._ Pediatrics, 1996. **98**(3): p. 378-382.
2. Taggart, N.W., et al., _Immediate Outcomes of Covered Stent Placement for Treatment or Prevention of Aortic Wall Injury Associated With Coarctation of the Aorta (COAST II)._ JACC: Cardiovascular Interventions, 2016. **9**(5): p. 484-493.
3. Meadows, J., et al., _Intermediate Outcomes in the Prospective, Multicenter Coarctation of the Aorta Stent Trial (COAST)._Circulation, 2015. **131**(19): p. 1656-1664.



Coarctation of the Aorta – An Incidental Finding

This course will explore basic and cutting-edge imaging techniques to improve patient care and hone individual skills in performance and interpretation of echocardiography, nuclear cardiology, cardiac computed tomography, and cardiovascular magnetic resonance imaging. Days will reinforce how cardiovascular imaging may improve comprehension in ischemic heart disease, structural heart disease, cardiomyopathies, and heart failure. Experts will utilize novel techniques to reinforce key topics including taped interventional cases and a strong emphasis on case presentations.